Team Member - Claim Control (Thane )

Birla Carbon; Thane; On-site; INR 600,000 - 800,000; Full time

Job summary

Birla Carbon is seeking a Team Member – Claims Control in Thane, Maharashtra, responsible for establishing a claims control framework ensuring regulatory compliance and risk mitigation. You will implement monitoring mechanisms, conduct audits, and improve processes, all while leveraging analytics and dashboards.

The ideal candidate should have strong analytical skills, a background in claims management, and experience with regulatory compliance in the health insurance sector. This is a key role focused on enhancing operational efficiency and maintaining quality across claims processing.

Qualifications

• Experience in claims control and governance processes.
• Strong analytical skills, proficient in Excel and SQL.
• Understanding of regulatory compliance and quality assurance in the insurance industry.

Responsibilities

• Implement end-to-end claim control frameworks and monitoring mechanisms.
• Ensure adherence to regulatory standards and internal guidelines.
• Conduct periodic quality audits and high-value claim reviews.

Job description

Role Title

Team Member – Claims Control

Job Purpose

The role is responsible for establishing and maintaining a robust claims control framework that ensures regulatory compliance, quality assurance, and risk mitigation across the claims process. It drives governance through audits, fraud prevention, and leakage control, while leveraging MIS, analytics, and dashboards to provide actionable insights. The position also focuses on continuous process improvement and automation, enabling efficiency, transparency, and adherence to industry standards in claims management.

Job Context & Major Challenges

About the Health Insurance Industry – The market is dominated by a few major players, with a significant share of business renewing with existing providers. Capturing new business opportunities in segments such as SME and start‑ups is a key challenge. Market dynamics, evolving customer expectations, and the need for wellness‑focused, technology‑enabled solutions add further complexity to the role. Aditya Birla Health Insurance Co. Ltd aims to differentiate itself with a unique business proposition – a comprehensive wellness program, chronic care management, a digital, paperless approach, and strong analytical capabilities to support timely MIS and regulatory data submission.

Key Result Areas

• Claims Control Framework & Governance – Implement end‑to‑end claim control frameworks, SOPs, checklists, and monitoring mechanisms.
• Regulatory & Compliance Adherence – Ensure adherence to IRDAI regulations, TAT norms, policy wording and internal guidelines.
• Claims Quality & Risk Reviews – Conduct periodic claim quality audits, high‑value claim reviews and exception analysis; identify risk indicators, trends and root causes; recommend preventive and detective controls; develop control MIS, dashboards and analytical reports using Excel, SQL or other tools.
• Process Improvement & Automation – Identify control gaps and drive process simplification, automation and system enhancements.